Application

Online Application

Street
City, Province, Country
Zip Code
Home/Main
Cell
Street
City, Province, Country
Zip Code
Name
street
Date
City, Province, Country
Citizenship
State and/or Country
Year Issued
List all research works that you have conducted or participated (type, purpose, subject matter, descriptions, institution where it was conducted, supervisor and whether it was published:
List the publishers and dates of books, monographs, or pamphlets published
List the titles of articles (Journals and dates) published or unpublished:
List recent seminars, medical meetings, symposiums, and conferences attended:
List awards and honors received:
Specialty List available on website
I certify that I Voluntarily enroll and willingly support the concept of Continuing Education Programs for doctors. I am licensed in the country where I intend to use the /Memberships, Fellowships, and Diplomas certificate (s) that I am applying for. I am enclosing a $300 non-refundable application fee OR the complete tuition fee. I understand that no action will be taken on my application without payment of fee and submitting all the required credentials. I authorize full investigation of my application. My signature below is the authorization to anyone to release any information you may request on me. I agree that my competency in clinical skills and professional qualifications will be evaluated and the Royal College may make inquiry or release information about me concerning this matter. I agree to indemnify, release and hold harmless the Royal College of Physicians and Surgeons and its Agents from any liabilities or torts by reason of their acts or omissions in connection with this application. I agree to abide by the decision of the Royal College or its agents. We agree to submit to arbitration under the American Arbitration Association for any controversy, claims, torts and tort nuisance and other related violations. We are to submit the above controversies to above arbitrators in Detroit, Michigan, USA, and a judgment of the competent court may enter such award of the arbitrators. I agree to function within the limits of my competency and I guarantee and warrant that the Royal College of Physicians and Surgeons (and its agents) assume no responsibility for any of my activities or actions. It is understood by me that any falsification of records, misrepresentation of material facts, dishonesty, forgery, and unethical practices will automatically render any Memberships, Fellowships or Diplomas certifications awarded to me NULL and Void. Under penalty of perjury, I guarantee and warrant that all information provided on all pages of this application are true and correct. I am legally bound by the foregoing as attested to here with my signature below. The Royal College of Physicians and Surgeons admits professionals to its organizations of any race, color, national origin, sex, age, handicap, or religious preference in its education programs, activities, and employment as required by the Civil Rights Act of 1964 and Amendments including Title IX of the Educational Amendments of 1972.